Coordinated STEMI Care Results in More Rapid Diagnosis and Treatment

An agreed-upon plan of action that teams up hospitals and emergency medical services (EMS) in individual regions of the United States can speed the diagnosis and care of STEMI patients, increasing the percentage who are treated within time windows set forth by national guideline recommendations. 

“The most important message is that it is possible to do this,” senior author Christopher Granger, MD (Duke University, Durham, NC), told TCTMD in an interview. “It is possible to have regions get together and collect data and [use] common protocols. And in doing so, we saw statistically significant improvement in the performance of timely reperfusion.” The study, led by James G. Jollis, MD (University of North Carolina, Chapel Hill, NC), was published online August 1, 2016, ahead of print in Circulation.

Collaboration and Customization Are Key

According to Granger, the American Heart Association Mission: Lifeline STEMI Systems Accelerator project was built on the lessons learned from Mission: Lifeline and involved collaboration and customization between hospitals and EMS that were unique to each region that participated. The effort, carried out between July 2012 and December 2013, was the largest ever to organize regional STEMI care in the United States. It involved 484 hospitals and 1,253 EMS agencies in 16 regions of the country. The regions included New York City, Atlanta, Houston, and St. Louis, and accounted for about one in four patients enrolled in the National Cardiovascular Data Registry ACTION Registry.

Of the 23,809 patients presenting with STEMI, 11,765 were transported by EMS and 6,502 self-transported directly to PCI-capable hospitals; the remaining 5,542 patients presented to non-PCI-capable centers and required transfers.

Over the course of the project, modest increases were seen in the percentage of patients who met guideline goals of first medical contact-to-device time of less than 90 minutes when presenting directly to PCI-capable hospitals (from 59% to 61%; P = 0.005). Individually, those transported by EMS improved from 50% to 55% (P < 0.001), while the rate of timely care among those transferred increased from 44% to 48% (P = 0.002). Additionally, among the five most improved regions for EMS-transported patients, the number treated within 90 minutes rose by 12%.

Mortality rates were highest for EMS-transported patients (8.2%) and lowest for self-transported patients (2.7%) presenting directly to PCI-capable hospitals. While there were no statistically significant changes in in-hospital mortality within any of the patient groups, there was a trend for lower mortality in the last quarter of the project among patients treated at Accelerator hospitals compared with other national hospital systems not involved in the program.

Ongoing Challenges for STEMI Care

According to the study authors, approximately 30% to 50% of STEMI patients nationwide are not treated within the times set forth by national treatment guidelines despite a nearly 50% increase in the number of PCI-capable hospitals across the United States in recent years, as well as the fact that 90% of Americans live within 60 minutes of such a center.

To TCTMD, Granger said the Accelerator project turned up some unique features of STEMI care in certain regions of the country. New York, for example, has a central call center that all ECGs must go to for interpretation. Another important aspect of the coordinated effort, he added, is the feedback received that enhanced communication between EMS and others was meaningful to those who participated in the program.

“We believe this program did something which is likely to translate into further benefit over time simple because it does take time to fully implement these interventions,” Granger added. Importantly, he said, a critical question is whether the regional STEMI networks can sustain what they have shown themselves capable of doing.

“What we know is that most of these regions have continued to have their regional meetings and their regional reports, so we believe most of them have been able to sustain and build upon the efforts begun in this project,” Granger said. As for how it may impact the rest of the country, his group is embarking on a second Accelerator project that will extend the concept to additional regions looking to coordinate their STEMI networks. That project also will take a broader look at how regional networks improve STEMI care all the way through discharge and the first year, he noted.

“We hope to get the message out that this is something that many, many regions of the country can do successfully and it will improve care for their patients,” Granger concluded.

But in an editorial accompanying the study, Alice K. Jacobs, MD (Boston Medical Center, Boston, MA), notes that multiple challenges remain, including in the areas of symptom onset to first medical contact and patient activation of EMS, both of which have improved little over the years.

“While continuing to meet door-to-device goals where much progress has been made (although the number of accepted exclusions has increased), we must turn our efforts to prehospital care and decreasing total ischemic time,” Jacobs writes. Cost-effectiveness of regional STEMI systems has yet to be clearly demonstrated, she points out, and few data exist on the status and quality of STEMI care in community hospitals that lack PCI capability or do not participate in national registries. Only about 20% of the nearly 5,000 nonfederal acute care hospitals in the United States participate in the National Cardiovascular Data Registry’s ACTION Registry-Get With The Guidelines program, Jacobs says.

Sources:

• Jollis JG, Al-Khalidi HR, Roettig ML, et al. Regional systems of care demonstration project American Heart Association Mission: Lifeline STEMI systems accelerator. Circulation. 2016;134:365-374.  
• Jacobs AK. The challenge to implement systems of care for ST-segment–elevation myocardial infarction. Circulation. 2016;134:375-377.

Disclosures:

• The Regional Systems of Care Demonstration Project: Mission: Lifeline STEMI Systems Accelerator is funded in part by grants from Abiomed, Philips Healthcare, and The Medicines Company. 
• Granger reports research support and consulting fees from multiple pharmaceutical companies. 
• Jacobs reports no relevant conflicts of interest. 

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